The Problem with Diagnosing Depression Across Cultures Part 1: Are Idioms of Distress Culturally Specific?

Image Source:  http://www.rajasthanonline.in/About/tourism/religious-spots/index.html

An aura of uncertainty and even scepticism often accompanies explanations of certain mental illnesses.  Depression is among the many disorders listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (or DSM) that, despite its aforementioned presence in such a conscientiously and methodically organised manual for categorising vocabularies and narratives of distress, eludes proper definition among both scholars and the laity to this day.  This kind of situation occurs within the cultural purlieu of the DSM’s conception and non-Western societies alike.  Since idioms of suffering vary worldwide, one can envisage the problematic nature of the claim that a category conceived in the United States can be applied universally.

Therefore I argue that idioms of despair and suffering, to a large extent, are culturally specific – and to do so I use a plethora of ethnographic material from various societies and peoples of Asia.  I draw on Harvard University’s Arthur Kleinman’s analysis of neurasthenia in China (1986), Anubha Sood’s (from Southern Methodist University) fieldwork at the Balaji Temple in Rajasthan, Northern India (2016),  Loo and Furnham’s study about knowledge of depression among the Indian community in Malaysia (2013), Byron Good (Harvard University) et al’s analysis of depressive symptoms as cultural and religious experiences in Iran (1985), Saiba Varma’s (UC San Diego) fieldwork at a public psychiatric hospital in Srinagar, Kashmir (2016), a study conducted on the perception of mental health stigma in rural and urban Hanoi, Vietnam (Hahn et al. 2016), and hwabyung (‘fire illness’) in Korea, among others.

These ethnographic data demonstrate that, apart from the medical symptoms-based model that is most prevalent along the Atlantic, distress can also often be expressed in bodily terms (known as ‘somatisation’ from Ancient Greek sōma ‘body’), in terms of exogenous factors such as societal and family life, and religious and spiritual terms.  Moreover, these expressions often conflict with idioms expressing mental illness in psychiatric discourse, which, despite their roots in the West, are nonetheless referred to by many clinicians worldwide.

Somatisation refers to the expression of distress through bodily idioms, and is a common mode of expression throughout societies in Asia.  Whereas in Western psychiatry, the cause for depression is often defined in terms of mental states and completely divorced from any bodily factors, those who meet the DSM criteria for major depression throughout the East, will often cite aches and pains to characterise their condition.  Among such bodily idioms are ‘heart distress’ in Iran (Good 1997), ‘gastrointestinal complaints among Cambodian and Vietnamese refugees in North America’ (Jenkins, Kleinman and Good 1991), soul loss or loss of vital essence among the Hmong of China, Vietnam and Laos, dizziness, headaches, insomnia, exhaustion of the nerves, and ‘hearts being squeezed and weighed down’ in China (Jenkins, Kleinman and Good 1991), and so on.

In fact, since somatic idioms of distress are the predominant mode of expressing distress in China, ‘depression’ is rarely diagnosed there; instead it is neurasthenia that is the most common neurotic affliction.  Conversely in the West, neurasthenia was removed from the DSM in 1980, even though somatisation is likewise not uncommon in Western contexts (e.g. ‘heartbreak’ or ‘chronic fatigue’).

Kleinman (1986) demonstrates in his study of neurasthenia in China that expressions of distress are not only expressed in bodily terms, but also that these expressions are enmeshed, both within the wider macrosocial environment of work in a Communist society, and the microsocial context of family and domestic life.  In Kleinman’s case study of one prolific and accomplished school administrator (name undisclosed), who suffered from neurasthenic symptoms, both the causes and effects of her condition were situated on factors outside herself – namely the stresses and pressures faced at work, problems with the Communist party secretary, and having let her sister down, who was passed away for quite some time, through her perceived failure to replace her as her niece’s mother.  These factors contributed to inability to perform at work, leading to somatic expressions of dizziness, exhaustion of the nerves, and so on.  According to Kleinman and Good (1985), neurasthenic patients in China, such as our school administrator, would in fact meet the diagnostic criteria for Depression.  However this would require interpreting a societally-oriented Chinese reality of illness, through a self-oriented Western lens, thereby ignoring the external factors that would be given salience by patients in China.

Family and social life also feature prominently in idioms of distress in societies other than China.  ‘Love-failure’ was used as a label to describe being unmarried and having failed relationships in rural India and Pakistan (Kermode et al 2009, Suhail 2005).  Symptoms of depression being parts of the everyday experience of love and relationships is also shared with Iran (Dejman et al 2010), and is a common theme in Persian poetry.  Mangala and Thara (2009) remark that symptoms of mental illness resulting from failed relationships are depicted in Hindi Bollywood films, and there is also strong emphasis on failed marriages being a cause of family conflicts in Indian reality, leading to depressive illness and suicide especially in women (Anand & Cochrane 2005; Pereira et al 2007).

Loo and Furnham’s (2013) study, of knowledge of depression as an illness among Indians in Malaysia, attests to the interpretations deduced hitherto, which identify exogenous factors as a cause of depression.  A pair of vignettes used by Loo and Furnham, of a patient with symptoms of depression, were shown to both urban and rural participants.  The only difference between the two vignettes was that one showed suicidal tendencies.  Significantly, the rural participants mentioned ‘familial and family obligations’ as a cause for the afflictions portrayed in both vignettes (Loo and Furnham 2013).  This was less so for urban participants, on whom the Western psychiatric paradigm of mental illness was more likely to have had an influence, as it is far more likely to be prevalent in urban environments where the effects of globalisation and modernisation can be felt the most.

A sociological cause of distress besides family ties, particular to South Asia, is the contagion of mental illness.  A socially enmeshed idiom in Srinagar, Kashmir, about how women who roam around without any kin are considered excessively bold and hence stigmatised, is metaphorically transferred back and forth between those who are manic, and those exhibiting the aforementioned behaviours which are seen, in the Kashmiri context (often derogatorily), to correspond with a diagnosis of mania.  This leads to perceiving mental illness as being contagious, and needing to be contained:

‘In contrast to official state decrees that “prison-like gate enclosures must be removed” and “cells must be abolished” [National Human Rights Commission of India, 1999], the everyday language of the doctors suggested that… the severely ill were contagious and needed to be quarantined.  Thus, while some patients were considered the appropriate subjects of modern, psychiatric care, others, particularly women who demonstrated an unregulated or dangerous sexuality, were not.’  (Varma 2016, p.794)

Although the Western paradigm of mental illness is not as prevalent in rural areas throughout countries in Asia, it is a mistake to believe that only rural sufferers of depressive disorders use indigenous, non-psychiatric alternatives to seek treatment.  In Sood’s study of the Balaji Temple in Rajasthan, Northern India, she notes many of the Sankatwale – pl. ‘those in danger (from spirit affliction)’, sg. Sankatwala (masc.) and Sankatwali (fem.) – came from urban and middle class backgrounds who sought help from the temple after having already attempted modern psychiatric treatment, which, unfortunately, had not worked for them.

Reasons for visiting Balaji include behaving in a ‘socially inappropriate or destructive manner’, suffering ‘from disturbing thoughts (man mein shanti na hona), unexplainable fears (bina karan bhay)’, and ‘vague bodily aches (shareer dard akarna)’ (Sood 2016 p.772).  These symptoms bear striking resemblance to affective, dissociative, psychotic and psychosomatic disorders respectively (Sood 2016).

templemap

In her work Sood demonstrates, that although disapproved of by the World Health Organisation and the National Human Rights Commission of India, temple practices do in fact provide effective relief for those suffering from depressive disorders, which are recognised here as spirit afflictions.  In fact, it is the very recognising of these disorders as spirit afflictions that make treatment at the temple affective.  Tapasya (asceticism), Bhakti (devotion) towards Balaji, and Peshi (trance rituals) are the primary methods of treatment at the temple, among others.  Although many of these practices are seen as inflicting voluntary pain on oneself, seen as a symptom of mental illness rather than a remedy in the Western psychiatric paradigm, these practices conversely are not only seen as ‘systematised therapeutic techniques’ (Sood 2016) but also give the afflicti agency and power over their affliction, which they were unable to obtain from psychiatry.  The result is an effective, culturally and contextually valid remedy.  The agency given by the practices of asceticism and devotion allow Sankatwale to assert control over their illness, akin to mindfulness meditation and forms of New Age healing, which are growing in popularity in the West.

Continued in Part 2:  Why is it difficult to diagnose depression outside western Contexts?

References:

Freud, S. (1917). Mourning and Melancholia in Freud, S. (1917). On Murder, Mourning and Melancholia. Trans. Shaun Whiteside (2005). London: Penguin Books.  Pp.201-18

Healy, D. (2004). Shaping the Intimate: Influences on the Experience of Everyday Nerves. Social Studies of Science 34(2) (April 2004).  Pp. 219-245

Horowitz, A. (2014). The Social Function of Natural Kinds. The Case of Major Depression.  in Kincaid, H. & Sullivan J.  (eds.) (2014).  Classifying Pychopathology: Mental Kinds and Natural Kinds. Cambridge Massachusetts:  MIT Press.  Pp. 209-227

Kleinman, A. & Good, B.  (1985). Culture and depression: Studies in the Anthropology of Cross-Culture Psychiatry of Affect and Disorder. Berkeley: University of California Press.

Jain, S., & Orr, D. M. (2016). Ethnographic perspectives on global mental health. Transcultural Psychiatry.  53(6).  Pp. 685-695. doi:10.1177/1363461516679322

Jenkins, H.  Kleinman, A.  Good, B. (1991). Cross-Cultural Studies of Depression. in Becker, J. & Kleinman A. (eds.) (1991). Psychosocial Aspects of Depression.  London:  Lawrence Erlbaum Associates, Publishers. Pp.67-99

Kirmayer, L.  (2001). Cultural Variations in the Clinical Presentation of Depression and Anxiety: Implications for Diagnosis and Treatment. Journal of Clinical Psychiatry 62 (suppl. 13): Pp. 22-30

Kleinman, A.  & Kleinman J. (1985).  Somatization: The Interconnections in Chinese Society among Culture, Depressive Experiences and Meaning of Pain. in Kleinman, A & Good B. (eds). (1985). Culture and depression: studies in the anthropology of cross-culture psychiatry of affect and disorder. Berkeley, California: University of California Press.

Kleinman A. (1986).  Social Origins of Distress and Disease: Depression, Neurasthnia and Pain in Modern China. New Haven, Connecticut:  Yale University Press.

Loo, P., & Furnham, A. (2013). Knowledge and Beliefs about Depression among Urban and Rural Indian MalaysiansMental Health, Religion & Culture,16(10), Pp. 1009-1029. doi:10.1080/13674676.2012.728579

Sood, A. (2016). The Global Mental Health Movement and its Impact on Traditional Healing in India: A Case Study of the Balaji Temple in Rajasthan. Transcultural Psychiatry,53(6), 766-782. doi:10.1177/1363461516679352

Summerfield, D.  (2006). Depression: Epidemic or Pseudo-epidemic? Journal of the Royal Society of Medicine 99 (March):  Pp. 161-162

Ta, T. M.  Zieger, A., Schomerus, G., Cao, T. D., Dettling, M., Do, X. T…. Hahn, E. (2016). Influence of Urbanity on Perception of Mental Illness Stigma: a Population Based Study in Urban and Rural Hanoi, Vietnam. International Journal of Social Psychiatry, 62(8).  Pp. 685-695. doi:10.1177/0020764016670430

Varma, S. (2016). Disappearing the Asylum: Modernizing Psychiatry and Generating Manpower in IndiaTranscultural Psychiatry,53(6), 783-803. doi:10.1177/1363461516663437

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